# NTSB CHI95LA104: Piper PA-28-181, N4385M, Ann Arbor, MI, March 19, 1995 - Type: NTSB accident investigation - Classification: Accident · Minor injuries · Limited investigation · Final report - Date: March 19, 1995, 15:02 local (20:02 UTC) - Place: Ann Arbor, MI - Coordinates: 42.259498, -83.849967 (estimated) - Nearby events: https://openairdocs.org/map.md?lat=42.2595&lon=-83.8500&mi=10 - Phase of flight: [Emergency descent](https://openairdocs.org/ntsb-phases/600) (OpenAirDocs' grouping) - Highest injury: Minor injuries - Injuries: 1 minor, 1 uninjured - Status: Completed, report August 23, 1995 - Report: Approved by Office Director - NTSB case key (mKey): 9853 - NTSB case page: https://web.ntsb.gov/investigations/?ntsbnumber=CHI95LA104 - NTSB report (PDF, downloads): https://data.ntsb.gov/carol-repgen/api/Aviation/ReportMain/GenerateNewestReport/9853/pdf - Page: https://openairdocs.org/ntsb/CHI95LA104 ## Probable cause the failure of the mechanic to close the drain valve after changing oil, resulting in complete loss of engine oil. A factor was the soft terrain, which resulted in the nose wheel digging in and the airplane nosing over. ## Sequence of events In NTSB's coding before 2008 (https://www.ntsb.gov/GILS/Documents/codman.pdf). - Loss of engine power(total) - mech failure/malf, emergency descent/landing - lubricating system,oil quickdrain/drain plug - open (contributing factor) - maintenance - improper, other maintenance personnel (cause) - fluid,oil - loss,total - powerplant - seized - Forced landing, emergency descent/landing - Nose gear collapsed, emergency landing - terrain condition - soft (contributing factor) - Nose over, emergency landing ## Analysis TEN MINUTES AFTER TAKEOFF THE OIL PRESSURE DROPPED TO ZERO AND THE PILOT ATTEMPTED TO RETURN TO THE AIRPORT. THE ENGINE BEGAN TO SEIZE, THE PILOT PULLED MIXTURE TO IDLE-CUTOFF, AND PERFORMED A FORCED LANDING IN A FIELD. THE NOSE WHEEL DUG INTO THE SOFT GROUND, AND THE AIRPLANE NOSED OVER. THE OIL DRAIN VALVE WAS FOUND IN THE OPEN POSITION, WITH FRESH OIL ON THE AIRPLANE. THE MECHANIC STATED HE HAD PLACED A PAPER PLUG IN THE DRAIN TO PREVENT DRIPS, AND FAILED TO CLOSE THE VALVE. ## Factual narrative On March 19, 1995, at 1502 eastern standard time (EST), a Piper PA-28-181, N4385M, operated as a rental airplane by Ann Arbor Flyers, Incorporated, of Ann Arbor, Michigan, impacted in a level field two miles northwest of Ann Arbor Municipal Airport (ARB), and was substantially damaged. The private pilot was uninjured, and the passenger received minor injuries. No fire occurred. Visual meteorological conditions existed at the time of the accident, no flight plan was filed. The flight originated at 1445 EST, as a 14 CFR Part 91 local pleasure flight. The pilot reported that during her preflight, the engine was being recowled after a scheduled oil change. She reported that during her engine runup, all indications were normal, but during the initial climb, ten minutes after takeoff, oil pressure dropped to zero (0). During her precautionary return to ARB, the engine began to run rough, she selected an off airport field to land in, and secured the engine. During the forced landing in an uncultivated field, the nose wheel broke off and the airplane flipped over. The mechanic who had changed the oil stated "When draining was complete an external drain tube was removed without closing the valve. Then a paper plug was inserted in the valve to avoid drips inside the cowl from the 'closed' valve. This plug prevented what should have been obvious flow thru onto the floor at the time of refill." Post crash inspection revealed the engine oil quick drain in the open position, and the bottom of the airplane covered with engine oil. ## Aircraft - Registration: [N4385M](https://openairdocs.org/aircraft/N4385M), registered now, S/N 28-8590025, built 1984 (OpenAirDocs) - Reported make and model: PIPER PA-28-181 - Registry model: [Piper PA-28-181](https://openairdocs.org/model/piper-pa-28-181) (registry code 7102807) (OpenAirDocs) - Registry engine: [Lycoming O&VO-360 series](https://openairdocs.org/engine/lycoming-o-vo-360-series) (registry code 41514, reciprocating) (OpenAirDocs) - Category: Airplane - Serial number: 28-8590025 - Engines: LYCOMING O-360 180 horsepower reciprocating - Damage: Substantial damage - Flight: Personal, Part 91 - Registered owner: Ann Arbor Flyers, Inc - Airworthiness certificate: Standard, Normal - Last inspection: Annual, March 18, 1995, 0 hours before - Departed: ARB, MI ## Flight crew As NTSB recorded them. NTSB leaves out names. - Pilot; age 32; private; airplane ratings: single-engine land; instrument ratings: airplane; medical: class 3, valid medical--w/ waivers/lim; seat: left; flight hours: 399 total, 271 in this make and model, 332 as pilot in command, 5 in the last 90 days, 2 in the last 30 days ## Weather - Conditions: Visual (VMC), Day - Wind: 170° at 13 knots - Visibility: 10 statute miles - Lowest ceiling: 6,500 ft broken - Temperature: 54 °F, dew point 36 °F - Altimeter: 29.00 inHg - Observed at: ARB, 2 nm away ## FAA reports on this event (1) The FAA's own accident and incident reports, matched to the aircraft by N-number and date (OpenAirDocs). - [Accident 19950319004329A](https://openairdocs.org/incident/19950319004329A), Mar 19, 1995: Piper PA28181, Ann Arbor, MI, Substantial damage. Lost oil pressure shortly after takeoff. Shutdown. Nosed over landing. Oil drain valve open. Mechanic failed close. (-23) shortly after takeoff from the Ann… From the NTSB's public API. Aircraft are matched to registry aircraft by N-number and event date, checked against the reported serial number, make and model; the registry's history has gaps, so older matches can be wrong. Compare the reported make and model. --- OpenAirDocs.org is an independent research project of [Contrail Labs](https://contraillabs.com/). It is not affiliated with the FAA or the NTSB. Source documents are U.S. government works in the public domain.